Acute acalculous cholecystitis on a COVID-19 patient: a case report

Abstract

Introduction We report an extremely rare case of acute acalculous cholecystitis on a COVID-19 patient. In our knowledge, this is the first report of laparoscopic cholecystectomy performed on a COVID-19 patient. Presentation of case A COVID-19 patient was diagnosed with acute acalculous cholecystitis and a multidisciplinary team decided to perform a percutaneous transhepatic biliary drainage (PTBD) as the first treatment. SARS-CoV-2 RNA was not found in the bile fluid. Because of deterioration of the patient's clinical conditions, laparoscopic cholecystectomy had to be performed and since the gallbladder was gangrenous, the severe inflammation made surgery difficult to perform. Discussion Acalculous cholecystitis was related with mechanical ventilation and prolonged total parenteral nutrition, in this case the gangrenous histopathology pattern and the gallbladder wall ischemia was probably caused by vascular insufficiency secondary to severe acute respiratory distress syndrome of COVID-19 pneumonia. The percutaneous transhepatic gallbladder drainage (PTBD) was performed according to Tokyo Guidelines because of high surgical risk. Laparoscopic cholecystectomy was next performed due to no clinical improvement. The absence of viral RNA in the bile highlights that SARS-CoV-2 is not eliminated with the bile while it probably infects small intestinal enterocytes which is responsible of gastrointestinal symptoms such as anorexia, nausea, vomiting, and diarrhoea. Conclusions Although the lack of evidence and guidelines about the management of patient with acute cholecystitis during COVID-19 pandemic, laparoscopic cholecystectomy, at most preceded by PTGBD on high surgical risk patients, remains the gold standard for the treatment of acute cholecystitis on COVID-19 patients.

Post COVID 19 acute acalculous cholecystitis raising the possibility of underlying dysregulated immune response, a case report

“…The reported mortality is from 30 to 50% depending upon the clinical state of the patient [ 4 ]. The majority of patients with acalculous cholecystitis have multiple risk factors such as trauma, cardiopulmonary resuscitation, mechanical ventilation, sepsis, burns, human immunodeficiency virus (HIV), immunocompromised states, prolonged total parenteral nutrition, and major surgery [ 4 , 6 ]. The pathogenesis is related to gall bladder stasis secondary to lack of gall bladder stimulation resulting in bile concentration and building up of intra-luminal pressure in the organ.…”

“…Recently a case report has described acalculous cholecystitis in a COVID 19 patient that was critically ill and was on mechanical ventilation [ 6 ]. The possibility of acalculous cholecystitis, in this case, could be related to severe illness, mechanical ventilation, and prolonged parenteral nutrition.…”

“…The possibility of acalculous cholecystitis, in this case, could be related to severe illness, mechanical ventilation, and prolonged parenteral nutrition. However, another plausible mechanism could be due to acute cytokine release syndrome which is also seen in COVID 19 patients and studied by Croteau et al in patients with relapsing-remitting multiple sclerosis during or shortly after alemtuzumab treatment [ 6 , 7 ]. The mechanism of injury in cytokine storm is poorly understood.…”

Implications of SARS‐CoV‐2 infection for neurogastroenterology

“…Several reports identified the presence of acute acalculous cholecystitis in COVID-19 patients. [111][112][113] No definitive data are available for explaining cholecystitis origin, which may be bloodstream-related or due to SARS-CoV-2 direct infection on bile ducts through ACE2 receptor binding, which levels are higher even in this district. 114 However, a case report on a resected gallbladder after cholecystitis highlighted the presence of SARS-CoV-2 within the tissue, thus confirming viral presence.…”

COVID-19-related cholecystitis

“…The second patient, an 83-year-old man, did not require surgery and was managed conservatively with a favorable outcome. There are few other reports of SARS-CoV-2 cholecystitis in younger patients [3] , [4] , [5] , [6] .…”